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EP monthly article by Greg Henry


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I'd like to get feedback on what our EM folks think about this system for large urban area EDs. In case the url doesn't work it is the immediate lead article this month in EP monthly at epmonthly.com concerning PA supervision and training in the ED. 

 

http://epmonthly.com/article/pa-training-oversight-model-worth-copying/ 

This was my response:

Curious how this system incorporates more senior, experienced PAs, or PAs who graduate PA school with significant EM experience (paramedic, combat medic, etc).

Also curious what the turnover is within the system.

I think it sounds like a great system, except for the glass ceiling where every level 3, 2, or 1 patient must be seen by the EP. Experienced PAs don’t need that level of oversight.

 

I think this is terrific, and hope it is the BEGINNING of a national model...one that then evolves into experienced PAs seeing the full spectrum of patients without required oversight.  

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Interesting read and not just pretty corporate talk, it's how it works (and at a full salary from day 1). 

 

It's a little more complicated than what they let on, but 1-3's basically need to have an attending involved. What that means is not exactly defined, thus it does build in some recognition of experience and trust of the particular clinician. There are PAs that have 10+ years working for MedStar. 

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Right.  It does not mean that the attending needs to see the patient from 1-3.  But his point is taken, if they can be sued for it, they should be briefed, as in there should be some presentation.  Basically, if they are responsible for the patient, which would be true in any ED setting where there was a physician present  (not a remote critical care site) they should at least probably be briefed as in "briefly". 

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I understand your point, but if so, then the EPs would have to be briefed on the 4 & 5s as well.

 

Why? Making this an all or nothing proposition is oversimplifying the situation, and there is no reason it has to be. For the most part, a new grad should be able to handle an ESI 4 or 5 without much hand holding. This allows for that (after 3 months). 

 

As a PA's experience and training increases, they can handle more complex patients, again, I don't think anyone disagrees with that either. This policy is generalized enough to allow for flexibility of EP involvement between PAs, years of experience, level of training, etc., while still acknowledging the medico-legal reality of the situation. While we would love for it to be true, I don't think that anyone could argue in court (and this is what the article is aiming at) that a PA should be seeing ESI 1,2,3's completely independently in an urban area. Rural, critical access hospital, with physician available by phone, that sounds reasonable, but the risk profile is completely different. North DC, a few miles from the Capitol, or Baltimore, a few miles from Johns Hopkins, not so much.

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sounds like a plan to control. Obviously he is trying to run th ER PAs like grunts. so at year five one has essentially 5 years of residency training in fast track? thats sh-t. Just a well planned assault on the profession to tightly control a profession.

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RPack said "If they can be sued for it, then they should be briefed."  I understand the sentiment (generally, the sentiment of fear and CYA) of this, but the EP could also be sued for a 4 or 5.  So extrapolating that sentiment, they should be briefed on all of those as well.

 

In reality, the EP (and us) can be sued for anything.  If a patient walks out without being seen by a provider at all they can still sue.  It's just the way the lawyers have the system set up.

I agree that having a "mid-level" see a potentially critically ill patient instead of the EP adds a level of complexity to any legal case, but the bottom line is experienced PAs are capable of taking care of critically ill patients.  Part of taking care of patients is being able to defend the care we give in court, no matter if that care is provided in an urban level I center or a rural ED.  

 

Again, I think this is a great start.  Funny thing is I just opened an email today from VEP (I work for them part time at a level II center) that spells out what cases I am required to brief the EP on.  My thought was "wow, this is going to really slow me down, cause I'm going to have to constantly be referring to this list to see what cases I am required to brief my boss on" because I am used to working rural places where if it comes in, I handle it.  

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I think that's the difference, rural vs urban level II/I. The expectation of the patient is very different, and thus the risk of litigation.

 

Law suits and making sense don't always follow. Just because something is medically defensible doesn't equal winning a law suit. It's just the unfortunate reality. Different risk environments call for different risk management strategies.

 

I bet you'll have that list memorized in a week and if you are as capable as you sound, I don't think it's going to be as big of a deal as you think. At this point, it's a part of being a PA and having an SP in busier EDs.

 

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I did not mean to imply that level 4/5 patients need to be presented if seen by an experienced PA anywhere.  That's like an urgent care or FP practice patient and we certainly have done enough of that autonomously so that it is not a controversy, or should not be, in court.  I guess the gestalt of it is that level 1,2,3 are higher risk and it is protective to both team members, MD and PA,  and the group itself to keep the MD in the loop.  That doesn't mean that the patient would need to be seen, although certainly that might occur.     I read recently in the academic life in emergency medicine blog that if you see 20 patients of all acuity a day in an ED you will statistically have one "bounce back" a day.    Everyone hates conversations that start "Do you remember that patient you saw Tuesday.........?"   Regardless of whether you are a PA or a doc, your stomach drops.  This is just a little bit more standard back-up for those occasions.....

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Expectation of the patient is different? If you mean urban patients are more demanding and entitled, then yes, I agree. One of the (many) reasons I practice rural medicine is because the 'quality' of the patients out here are generally much 'better' than the quality of patients in urban America.

Can't disagree with you there!

 

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sounds like a good model for new grads, but as boat says, where does the experienced pa fit in?

I wouldn't want to present that many pts to an attending. most of the time now I work solo, and when I do work with a doc we are alternating charts from the same rack. we talk to each other about cases, but there is no requirement that I present certain cases. my last double coverage shift we had 2 trauma pts from the same accident. we only discussed them after they were both dispo'd and only in conversation.

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sounds like a good model for new grads, but as boat says, where does the experienced pa fit in?

I wouldn't want to present that many pts to an attending. most of the time now I work solo, and when I do work with a doc we are alternating charts from the same rack. we talk to each other about cases, but there is no requirement that I present certain cases. my last double coverage shift we had 2 trauma pts from the same accident. we only discussed them after they were both dispo'd and only in conversation.

I think experienced EM PAs need to understand that the majority of PAs are what we call "green/new/fresh PAs" in ERs today. This hospital may have NEVER had an experienced PA come to work for their group and so all they know are providers with 4 weeks of ER clinical experience.

 

I have found there to be very few PAs coming out of schools today that are (1) dedicated to the EM profession (2) have the skills, mindset, personality, etc. to succeed and make a career as an independent EM PA. Most students find EM attractive because it's higher paying than primary care. They are young and they want excitement and think they will get that in an ER. They usually don't mind working weird shift schedules either.

 

This is just a 2-5 year thing for these PAs. They reach a plateau in salary by working in fast track and get burnt out by low acuity and never getting to really learn emergency medicine because no one will teach them. They then move on.

 

Honestly, I think PAs working high acuity cases in emergency medicine is starting to fade. The EM speciality is getting harder to match into for physicians and is definitely becoming more academic over the past 10 years. PA schools are pumping out high GPA/low HCE PAs who are not anywhere qualified to start working in ERs without constant supervision.

 

The only way PAs stay is through PA EM residencies and maybe through programs like this. Without them-- PAs will be manning fast tracks/glorified urgent cares in the near future and that will be the top of their scope.

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agree with above on all counts. the issue is the quality of entering pa students with low prior hce/life experience and the declining willingness of docs to train new grads. If I was a new grad today I would definitely do a residency, regardless of the field I wanted to pursue.

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agree with above on all counts. the issue is the quality of entering pa students with low prior hce/life experience and the declining willingness of docs to train new grads. If I was a new grad today I would definitely do a residency, regardless of the field I wanted to pursue.

 

  I think the day is coming when we see a "requirement" of residency training for employment in a specialty other then FM. Maybe not from the NCCPA or other governing bodies, but from employers. Think about it, a residency trained PA (speaking of new grads only) should be better equipped to "hit the ground running" thus requiring less OJT by the docs. And, In theory, it decreases the liability by not having a new grad in the given specialty In this case ED).   

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  I think the day is coming when we see a "requirement" of residency training for employment in a specialty other then FM. Maybe not from the NCCPA or other governing bodies, but from employers. Think about it, a residency trained PA (speaking of new grads only) should be better equipped to "hit the ground running" thus requiring less OJT by the docs. And, In theory, it decreases the liability by not having a new grad in the given specialty In this case ED).   

Probably mixed in with the CAQ.  Like the BC for EP.  Initially you could be a FP or IM physician and challenge the boards.  Now you gotta go through EM residency.  

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If you have a CAQ or a residency, I think you are out of this equation entirely.   Different animal.   Ditto if you work solo in a rural area, obviously.  But the vast majority of ED care is not by rural solo CAQ residency trained PAs, so I think actually this  plan has merit for specific situations  (Baltimore, Oakland CA, etc.).  We do need to differentiate because of experience, quals, locality, etc. 

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If you have a CAQ or a residency, I think you are out of this equation entirely.   Different animal.   Ditto if you work solo in a rural area, obviously.  But the vast majority of ED care is not by rural solo CAQ residency trained PAs, so I think actually this  plan has merit for specific situations  (Baltimore, Oakland CA, etc.).  We do need to differentiate because of experience, quals, locality, etc. 

agree. this is a great opportunity for a new grad. after a few years they can decide if the degree of supervision meets their long-term goals and desires.

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